Innovation in Primary Health Care in Dryden, Ontario: “It’s Your Health”

S U C C E S S S T O R Y

“It’s Your Health” Innovation in Primary Health Care in Dryden, Ontario1

This small city has faced its challenges squarely and made some very big

changes in the delivery of primary health care; changes that have resulted

in better access for patients, improved continuity of care and more seamless

patient flow between acute and primary health care services.

Ron T. is right, says Darlene Furlong, Senior Vice President of Patient Care Services of the Dryden Regional Health Centre.

“We have the same family physician shortages that other Ontario communi-ties are experiencing. Physicians have many options available to them today in terms of their scope of practice, working hours, and income. It’s all about lifestyle.”

The city of Dryden is located halfway between Winnipeg, Manitoba and Thunder Bay, Ontario, and about 160 km north of the US border.

The picturesque area has a myriad of pristine and exquisitely beautiful lakes and provides residents and visitors with a wide array of outdoor and other recreational opportunities. Population: 13,000 including the catchment area that surrounds Dryden. There are ten GPs in the community at present. Approximately 3,500 patients in Dryden are not rostered to a physician.

Ron T. is 72 years old. He’s lived in Dryden, Ontario for the past 50 years.“It’s hard to get Doctors to come here,” he says.

“Whenever someone sees a doc in the grocery store, they ask him for advice about their elbow or their knee!”

As a result, the old adage, “necessity is the mother of invention” kicked in. This small city has faced its challenges squarely and made some very big changes in the delivery of primary health care; changes that have resulted in better access for patients, improved continuity of care and more seamless patient flow between acute and primary health care services. It has developed a model of care which has won accolades for innovation around the province.

It all started about ten years ago. A group of concerned citizens called the “Dryden Cares Committee” got together to look at ways to help recruit and retain doctors for the community. This committee was transformed into a community foundation that

Health It’s Your

Innovation in Primary Health Care in Dryden, Ontario

1 “It’s Your Health” Innovation in Primary Health Care in Dryden, Ontario

1 “It’s Your Health” Innovation in Primary Health Care in Dryden, Ontario2

partnered with the local hospital (Dryden Regional Health Centre), the medical clinics, and the City of Dryden, to come up with strategies and plans to address their primary health care access problems. Working from this plan, the hospital purchased the two medical clinics and brought all of the physicians into one clinic. Through fundraising initiatives and significant support from the city and the hospital, a financial structure was put in place to support on-going recruitment of health care professionals. This new structure has enabled the community to offer turn-key practice opportunities and low overhead costs for new physi-cians considering a practice in Dryden.

Given the doctor shortage, and the reality that Dryden would not likely have enough doctors to meet their needs for some time, the hospital and the clinic began to work together to find viable solutions to this problem. When the Ministry of Health and Long- Term Care (MOHLTC) announced the creation of Family Health Teams for the province in 2004, this looked like

a perfect fit for Dryden. The medical clinic had already formed a Family Health Network. Then, the hospital and the medical clinic established a steering committee with key community stakeholders and a Family Health Team application was submitted. MOHLTC approvals followed and once the staffing was finalized, the neces-sary addition and renovations could be made to accommodate the new health care professionals. Two years ago, and after a significant amount of hard work, the plan became a reality. The Dryden area had a new Family Health Team of physicians, nurse prac-titioners, social workers, RNs, RPN’s, dietitians, pharmacists, clinical psy-chologists and diabetes educators.

Katherine Campbell, a community development consultant in the region, was hired to head up the new team.

“It was so exciting to have the opportunity to engage a community with the purpose of developing a health care team of providers focusing on coordinating care, improving access and chronic disease prevention and management.”

Katherine spent the first six months studying and researching models from across the country…

“We had to get it right!”

The team uses a self-management approach to care, working

in a collaborative partnership with the community and hospital.

As a result we can offer a wide array of new programs and services to our patients that support and empower them to improve their health.

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At Celebrating Innovations in Health Care Expo 2007, Katherine Campbell (centre), Director of Dryden Area Family Health Team, and Dianne Bishop (right), RN Health Promotion and Prevention Coordinator, accept an award from former Health Minister George Smitherman.

Eventually she began to hire some RNs to lay the groundwork.

Dianne Bishop was one of the first hired. For 20 years, she worked as a RN in community-based care. She was hired because she knew the community…

“I enjoy working with people in the community to improve their health. I can see the difference we are making.”

Soon Dianne was joined by other RNs and health care professionals and in November 2007, the Family Health Team members moved into a brand new building, physically attached to the existing clinic. One Board of Directors oversees both acute and pri-mary health care services. The admin-istration for the Family Health Team and the Regional Health Centre is provided by the hospital management. Katherine Campbell sits on several committees in the hospital and on the North West LHIN, making for easier integration of planning and programs.

Darlene Furlong feels this accounts in large part for the successes they have achieved: “We have a model that allows patients to move seamlessly back and forth between primary and acute care in a way that best matches needs of the patients with the appro-priate facilities, equipment, and health care professional expertise. Now, through the Family Health Team, we are able to provide a wide array of health care promotion and prevention programs and chronic disease management.”

“In our model we rely heavily on group programs for patient educa-tion, although individual counselling is offered depending on the client’s needs,” says Katherine Campbell, “this utilizes our limited resources effectively for all patients. The team uses a self-management approach to care, working in a collaborative

partnership with the community and hospital. As a result, we can offer a wide array of new programs and services to our patients that support and empower them to improve their health.”

The Dryden Area Family Health Team program that Katherine Campbell has put in place is called “It’s Your Health!” It’s comprised of three main components. The first is “Healthy Living”, a series of groups and programs for anyone in the community wishing to improve their health. It includes a prenatal program, a smoking cessation program, information on safe alcohol guidelines, healthy weights, nutrition, physical activity, stress and relaxation techniques and safe medication use.

The second stream of programs falls under the category, “Manage Your Health.” These are groups designed for patients who have been diagnosed with a chronic disease. Patients learn skills

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to help them self-manage and handle the day to day challenges of living with a chronic illness. Nutrition and mental health counselling form a large component of this category of service. “Manage Your Health” provides group education and individual appoint-ments for patients with asthma, COPD, hypertension, lipids, TIA/stroke, arthritis and diabetes management through funding from the Northern Diabetes Health Network. Staff have been trained in the Stanford Self-Management leadership course and look forward to adding the component to the “Manage Your Health” program.

The third component of the “It’s Your Health!” program is called “Your Health Toolkit.” This refers to the individualized care that’s provided by the Family Health Team or everything from primary care, to treatment of wounds, to well-baby and prenatal care, to immunizations and flu clinics.

Many of the programs are delivered through outreach to the community. This year schools, seniors’ centres and employees at Domtar, a large pulp and paper mill in town, were targeted for heart health risk factor screening and diabetes prevention education. Outreach to the community is an important aspect of the programs provided by the Family Health Team. Patients appreciate the opportunity to participate in community education sessions that support and target their health and well-being including the

option of follow up with a health care provider. New programs are constantly being added as resources become available. For example, mental health services and relationship counselling, will soon be enhanced by the addition of a clinical psychologist, who the hospital and Family Health Team are working together to hire.

When a patient arrives at the Family Health Team, whether referred by a physician or the hospital or self-referred, Charlene Hermanson-Smith, a RN and the Primary Care Coordinator in Dryden, does the intake. It takes an hour and consists of a thorough health assessment including blood pressure measurement. The patient then receives assistance in navigating the system to find the most appropriate resource or program. If a patient doesn’t have a physician and needs a diagnosis or other medical care, Charlene refers them to a nurse practitioner. In the near future, the program will include screening for cardiovascular disease, stroke and diabetes right at the point of intake.

Dr. Michael Cortens and dietitian Kerry Gagne look at healthy food choices.

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“We are pioneers as a family health team. Care is based on the individual patients needs and our approach is to assist them with setting their own personal goal(s). We always encourage patients to take charge of their own health.”

Long-time Dryden resident Ron T. is doing just that, thanks to the care he is receiving through the Family Health Team. Three years ago, he was diagnosed with anemia and high blood pressure. He was put on medication to deal with both problems and saw his physician whenever he could get an appointment.

“That was no easy task,” Ron says, “it would take me weeks to get in to see my doctor and then he was always in a hurry.”

But a year ago, Ron’s doctor referred him to other Family Health Team providers. First, he spent one full hour with Charlene. Using a self-management approach as she does with all the patients, Charlene helped Ron work out an action plan that involved more walking on a daily basis and a regular visit to see Kerry Gagne, the team dietitian.

“Before I see Kerry once a month, I have to get my blood work done. When I come into her office, she already has the results of my tests on the electronic medical record. We go over the results and I can understand what she tells me and I can see how well I’m doing with my diet. I have already got my weight and anemia under control and I look forward to seeing Kerry every month to monitor my progress. This is the best.”

Kerry also thinks it’s the best. “I am very privileged to be working

with this team. It allows me to provide patients with seamless care all under

the same roof. With electronic medical records, for example, I can see the results of my patients’ blood tests and if there’s a problem, I can flag the record for their physician and make an appointment for them.”

Sharon L. met Kerry Gagne at the Dryden Regional Health Centre. Sharon was hospitalized with severe chest pain. Her physician felt she needed to reduce her waist girth and lose some weight. He referred her to Kerry who visited her in hospital and then scheduled an appointment on discharge. Now, like Ron, Sharon sees Kerry once a month and also attends the Lipid Clinic once every three months. Here, she has the opportunity to hear from a pharmacist about medications, a dietitian about nutrition and a RN about exercise and other healthy lifestyle choices.

“Now I write down everything I eat in a diary and I bring it to Kerry. I feel she cares about me and I am accountable to her. She keeps me honest! Since I started coming here, I’ve lost an inch on my waist, my

Charlene Hermanson-Smith, Primary Care Coordinator, with a patient at intake.

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triglycerides are down and I’m walking a half hour a day.”

Aldene Rankin, a RN with years of community care experience and now the new Asthma and COPD Coordinator in Dryden, is impressed by the improvements patients like Sharon are making.

“It’s very different work…for me. I’m now involved in prevention and education programs in the community and people in the Dryden area are finally getting the resources, encouragement, and support that they need to take responsibility for their own health.”

The program is still in its infancy; the building barely open. Katherine Campbell says that one of her main tasks is educating the public about the programs and services that are available.

“People are not always familiar with an interdisciplinary approach to care.

We need to do more public education with the community demonstrating the benefits of a team approach to care that includes physicians working collaboratively with other health care providers. With a team approach to care, patients access the appropriate provider supporting their health care needs.”

“I have at least two people working with me now, my doctor and Kerry, the dietitian,” says Ron T., with a smile. “I feel like I’m twice as healthy!”

Sandra L. agrees: “I have a very good doctor, but with the Team, if I have a question, I just pick up the phone and ask them. It’s very comforting. I feel much more confident in my health.”

I have a very good doctor, but with the Team, if I have a question,

I just pick up the phone and ask them. It’s very comforting.

I feel much more confident in my health.

For more information, contact Katherine Campbell, Director of the Dryden Area Family Health Team: (807) 223-7406 x332; kcampbell@dh.dryden.on.ca